IPMH Joy Osofsky Weekend

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I am catching up on my infant parent postings by writing about a wonderful weekend with Joy Osofsky last month. In her first day of her teaching Joy began by introducing us to three evidence based interventions for very young children – Attachment and Bio-behavioral Catch-up (ABC),  Parent Child Interaction Therapy (PCIT), and Child-Parent Psychotherapy (CPP),  Although not exclusively used for this purpose, these interventions were designed to treat traumatized young children and their parents.

ABC is an intervention for parents of young children who have experienced adversity that helps parents recognize their children’s problematic coping strategies and recognize their own problematic parenting behaviors, so that they can create a caregiving environment that promotes their children’s bio-behavioral regulation. The intervention takes place in 10 sessions that target key issues for traumatized children and is manualized, though the relationship between the clinician and the parent is crucial to the success of the treatment. This intervention is particularly useful for foster parents of infants of toddlers 1-3-years old, high risk birth parents of infants and toddlers, and parents adopting internationally.

Two main emphases of ABC intervention are that (1) some children reject their caregivers even though they need nurturance, and (2) parents can sometimes behave in ways that frighten children, often without realizing it. When traumatized children behave in rejecting ways, their parents must learn to re-interpret their signals so that they can respond to them with effective nurturance. Also, parents who have been traumatized or frightened as young children will sometimes display an angry or frightened face to their child or even “tune out” (“dissociate”) in a way that may frighten a child. Parents with troubled past histories may also misinterpret their children’s expressions of distress and fail to respond in a comforting way. This intervention teaches parents to recognize patterns such as these in their own behavior and in that of their children so that they can learn optimal patterns of parenting behavior. These optimal behaviors include following the child’s lead with delight, attending to the child’s signals, supporting the child’s agency, and the importance of touch.

An interesting feature of this intervention is that of encouraging the parent to provide nurturance even if it doesn’t come naturally – “fake it until you make it”, as I say. We know that practicing a behavior can build new neural circuits in the brain, and ABC attempts to override the parents’ own problematic tendencies by building good nurturing behaviors that are practiced and reinforced in the relationship with the clinician. In this intervention, the parent’s problematic past is directly addressed as it is currently represented in the parent’s behavior towards her child.

PCIT is an intervention in which the clinician behind a two-way mirror coaches the parent through a bug in the parent’s ear. This is a strictly behavioral approach that incudes elements of family systems theory, learning theory, and traditional play therapy. The emphasis is on restructuring parent-child patterns, rather than modifying target behaviors. PCIT is designed to be most effective in treating disruptive behaviors. In this intervention, parents are not blamed but are given responsibility for improving their child’s behavior.

Decisions about family preservation, reunification, or permanency need to be made prior to beginning a course of PCIT, which takes place in 14-21 weekly sessions. Some of the limitations of PCIT are that it focuses on the child’s behavioral problems and parent skills but not on domestic violence, substance abuse, or parent psychopathology.

The third intervention, CPP, focuses on current stress and trauma as well as “ghosts from the nursery” in the past of the parents. This phrase is the title of a famous paper by Selma Fraiberg, a pioneer of parent-infant mental health and refers to traumatic experiences in the parents’ past that haunt them when they become parents themselves (Fraiberg, Adelson, & Shapiro, 1987). This intervention is also manualized and multi-theoretical.
The intervention uses play, physical contact, and language to further the child’s development. Symbolic play is used to create a “trauma narrative”. Games are used to help with emotional and physical regulation – such as blowing, patting, and breathing games. Mazes and other games are used to help a child gain a sense of his body in space, and touch is used to restore trust in physical contact. Another way of describing this intervention is that it is a combination of play and “unstructured developmental guidance”. Important feature of this guidance are to help the parent understand appropriate developmental expectations of their young child and to help both parent and child name and cope with strong feelings. In addition to modeling good parenting behaviors and offering concrete assistance, such as with safe housing, the clinician makes interpretations linking present to past and distant past, “ghosts in the nursery”. These interpretations create the “trauma narrative”.

An interesting and I think important study of the factors disrupting and facilitating emotion regulation is being conducted by a group in New York and Geneva. They suggest that the child’s helplessness, fear, and rage can elicit traumatic memory traces in the mother with PTSD (“ghosts in the nursery”) and propose to help the mother change her behavior in a similar way to the ABC protocol but with videotape feedback. Since I am familiar with videotape feedback and a big believer in its effectiveness, I am awaiting the results of this study with anticipation (Schachter and Rusconi Serpa, 2014).
Fraiberg, S., Adelson, E., & Shapiro, V. (1987). Ghosts in the nursery: A psychoanalytic approach to the problems of impaired infant– mother relationships. In S. Fraiberg (Ed.), Selected writings of Selma Fraiberg (pp. 101–136). Columbus: Ohio State University Press.

Schechter D, Rusconi Serpa S (2014). Understanding how traumatized mothers process their toddlers’ affective communication under stress: towards preventive intervention for families at high risk for intergenerational violence, in R Emde and M Leuzinger-Bohleber, Eds., Early Parenting and Prevention of Disorder, Karnac Press, pp. 90-117.

 

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